June, 2017

Guidemines

By Michael J. Katin, MD

Life is a challenge although the alternatives are somewhat limited. We have the opportunity to be temporarily distracted by the NBA Finals (NHL finals in selected regions) and social media, but eventually have to deal with reality. To put this into perspective, some potential crises are beyond our control. Less than two weeks ago Asteroid 2017 HX4, 108 feet in diameter, missed striking the Earth by 3.7 Lunar Distances, or 883,767.2 miles. This was only one of several near-misses over the past few months, including 2014 JO25, 2000 feet wide, on April 19, passing by at 4.7 Lunar Distances, and 2017 AG13, 112 feet in diameter, missing by only 0.54 Lunar Distances!

If we can forget about the fact that we live in this celestial shooting gallery, and disregard that the Yellowstone caldera is 40,000 years overdue for eruption, and that some of us will not be able to avoid seeing the fifth Pirates of the Caribbean epic, it is then possible to address the problems that are besetting us daily. It's difficult to be a functioning human being in this environment, and it's no wonder that physicians have a higher than average incidence of suicide and divorce and, sometimes, both.

Which finally bring us to the concern that things can, in fact, get more hazardous. For years, medical practitioners, and particularly those in oncology, tried their best to make sure the treatments being recommended were as contemporary as possible. This was accomplished through annual specialty conferences, constant review of the literature, and, primarily, frequent meetings with pharmaceutical representatives. Sometimes there were substantial disputes among specialties as to which course of treatment would be optimal, and it was hoped that at some point practice guidelines would be proposed to help reduce interdisciplinary strife and make sure the patient was not deprived of the best options. Years ago it was as basic as whether conservative breast surgery plus radiation therapy is equivalent to mastectomy in women with relatively early breast cancer. Surgeons had difficulty accepting that reducing the extent of surgery known to be definitive would still give similar results. As tends to occur, this now seems to have gone full circle with many women electing mastectomy for a variety of reasons. The question may arise whether this procedure should be done, or if it would be covered by insurers, if clinical practice guidelines indicate otherwise.

Now, with so many new developments and conflicting options, many of which are, unfortunately, not free of bias, practitioners may have accidentally entered a trap from which escape will not be possible.

We have been too successful in requesting input regarding which treatment programs are truly optimal, rather than being battered by the opinions of referring physicians. Over the past 30 years, results were generated by ECOG, NSABP, RTOG, and other study groups, and then usually ignored by practitioners with vested interests. Surgical specialty societies, such as the American College of Surgeons and American Urological Association being by their nature much more concrete than internists, started to promote guidelines for a few disease conditions. As time has gone on, nearly every professional medical organization, from the American Society of Clinical Oncology to the American Chiropractic Association, has promulgated its practice guidelines. There is even Guideline Central to compile guidelines from dozens of organizations. What's the trap? It's actually several traps. The first problem, of course, is that guidelines don't all agree totally with each other. Evidenced-based medicine will be wonderful as long as the evidence hasn't been contaminated. Second, when there are differences, is it possible that bureaucracies that score practitioners for quality measures or, even worse, evaluate diagnostic or treatment procedures for medical necessity to deny approval for coverage or to order repayment, may select only certain guidelines to use as their references? Third, it was considered a major advance when the National Comprehensive Cancer Network created guidelines for treatment for most types of cancer based on multidisciplinary input, but now updates are occurring almost weekly and it is difficult to make sure that all these are taken into account with each new patient seen in a busy practice. These updates now include increasing detail as to post-treatment management, psychosocial aspects, genetic counseling and more and more ancillary items that can easily be overlooked; are these responsibilities to be referred back to the primary physician or will have to be addressed by the oncologist in addition to managing the details and acute problems associated with treatments? NCCN publications are more and more being accepted as definitive; it is noted that, to its credit, the American Society for Radiation Oncology has cleverly labeled its equivalent guidelines as Clinical Practice Statements. Fourth, although transparency is always a good thing, most of these practice guidelines are now available to anyone through websites and apps; it is definitely a good thing for a person to be able to find out as much as possible about his or her disease, and this information is therefore also available to the insurance, business, and legal communities, with the potential to be misused for their own interests. Fifth, and worst, if an empowered entity decides on the "proper" treatment parameters for every disease, it won't be necessary any longer for physicians to have to participate. We will have the potential to devolve into the equivalent of the male anglerfish becoming a (legally, so far) necessary appendage to the cancer care behemoth but totally at its mercy.

Our only hope is to make sure that this is a benign entity. It would make a huge difference whether this were the President of ASCO, the Secretary of HHS, Dr. Dan Longo, the Surgeon General, or Dr. Ezekiel Emanuel.

There may be only one person with the charisma, education, and popularity who will be able to successfully handle this responsibility. I hope availability will not be an issue.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including June 1, 2017, this leaves 5,693 days to his goal.